Stroke
Stroke prevalence in HIV-positive patients exceeds that expected for age-matched HIV-negative subjects. Autopsy studies have yielded a high prevalence of infarction and parenchymal hemorrhage in HIV-positive patients.[33] Leading causes of stroke in HIV-infected patients are listed in Table 3. In intravenous drug addicts, bacterial endocarditis should be considered. Endocarditis leads to septic embolism and septic arteritis, and consequent arterial involvement can cause infarction or formation of a mycotic aneurysm, with intracerebral or subarachnoid hemorrhage. Mycotic aneurysms are small, located in distal branches of the arteries, and can be detected by conventional catheterization and less readily by magnetic resonance angiography; associated hemorrhage is detected by CT.[34] Treatment with appropriate antimicrobial agents may be associated with healing (angiographic disappearance of the aneurysm) without surgery.
In HIV-infected patients with stroke, lumbar puncture is necessary to exclude meningovascular syphilis or another infectious meningitis. Herpes zoster infection can involve the middle cerebral artery, causing arteritis. When ischemic stroke develops in an HIV-positive patient, examine the patient for skin lesions consistent with herpes zoster, especially for lesions located around the eye (ophthalmic division of trigeminal nerve) and contralateral to the stroke deficit.[35] Recreational drugs, especially cocaine, can cause either ischemic or hemorrhagic stroke. When brain hemorrhage complicates use of a sympathomimetic drug, angiography should be done to look for an underlying vascular lesion, aneurysm, arteriovenous malformation, or vasculitis.[36]
South Med J. 2001;94(3) © 2001 Lippincott Williams & Wilkins
Comments